Failure to Follow Physician Orders for Blood Glucose and Blood Pressure Management
Penalty
Summary
The facility failed to implement physician orders for two residents. For one resident with diabetes mellitus, staff were required to obtain glucometer readings and notify the physician if blood glucose levels reached or exceeded 400 mg/dL, as per the physician's order. On one occasion, the resident's blood glucose was recorded at 438 mg/dL, but there was no evidence that the physician was notified of this elevated result, contrary to the order. For another resident with hypertension, physician orders directed staff to check blood pressure twice daily and administer clonidine as needed if the systolic blood pressure exceeded 160 mm Hg or the diastolic exceeded 100 mm Hg. On two separate occasions, the resident's blood pressure readings met or exceeded these thresholds, but there was no evidence that clonidine was administered as ordered. The Director of Nursing confirmed that in both cases, staff did not follow the physician's orders regarding medication administration and notification.
Plan Of Correction
NotSpecified The facility will continue to implement physicians' orders. 1. R1 no longer resides at the facility. R2's MD and RP were notified of elevated BP on 7/11/2025 and 7/26/2025, and PRN not administered. No negative outcome to R2 noted. 2. Facility audit completed for like residents with sliding scale and blood pressure orders with parameters. 3. The Director of Nursing or designee will provide licensed nurses education on ensuring orders with parameters are being followed and have proper prompts, and notifying MD and RP. 4. The Director of Nursing/designee will audit cardiac medications and sliding scale orders weekly for 4 weeks. Results of audits will be reported to the QAPI Committee. 5. Date of compliance is 08/20/2025.